Payroll Deduction Authorization

I, ___________________, authorize Employer to deduct the following Amount of Deduction, $ _________, from my gross earnings for each payroll period beginning ___________ as detailed below:

This Deduction shall be for:

______________________ Date:

Employee Name

Payroll Deduction Authorization

Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This is simply good housekeeping to get these requests signed and in the employees’ files. There are a host of reasons to do so and none suggesting it is a problem.

Have the employee sign two copies, one for their records and one for the files.